Natural causes killed two-day-old baby - inquest

THE tragic death of a two-day-old baby from Redhill was due to natural causes, a coroner has ruled.

THE tragic death of a two-day-old baby from Redhill was due to natural causes, a coroner has ruled.

Tobias Taylor was born at East Surrey Hospital in Redhill on May 17 in 2009, and died two days later after being rushed to St George's Hospital in Tooting with septicaemia caused by a ruptured bowel.

His parents, who are both carriers of cystic fibrosis, said doctors should have assessed him for any problems or signs of complication before the standard 24-hour check, after ultrasound scans had highlighted a bowel abnormality and also because of their family history.

But paediatric experts and doctors said the parents should have listened to advice and stayed in hospital with Tobias instead of discharging themselves.

Following a two-day inquest at Woking Coroner's Court this week, assistant deputy coroner for Surrey, Alison Hewitt, said that although some things could have been done differently it did not seem any interventions would have led to a different outcome than the tragedy that happened.

Parents Marie and Simon Taylor, of Arbutus Road, also said staff should have explained the risks of leaving hospital before the mother discharged herself and Tobias and returned home.

Self-discharge form

The inquest heard the baby was born at 2am after a straightforward delivery, and weighed a healthy 7lb 8ozs.

Ultrasound scans had shown echogenic bowel, an irregularity in the appearance of the bowel which can be an early sign of medical problems, and they also picked up an abnormality known as dilated bowel loops.

When Tobias was born, staff were aware of the possible complications and doctors said the baby should stay in hospital for observations before being checked after 24 hours.

But Mr and Mrs Taylor - who have three children, two of whom have cycstic fibrosis - insisted he was checked sooner, the inquest was told.

When staff refused, the mother decided to discharge herself and her newborn son, signing a 'self-discharge contrary to medical advice' form.

Giving evidence at the inquest and through statements, several members of staff said they had tried to explain to Mrs Taylor that she and Tobias needed to stay in hospital.

An investigation into the case
, which was launched by Surrey and Sussex Healthcare NHS Trust following a complaint from the couple in 2009, found doctors failed to examine the baby within the first hours of his life despite knowing about his bowel irregularity.

Several senior doctors said they would have expected an examination of Tobias to have been conducted before 24 hours or before he was discharged due to the potential complications, but insisted such an examination may not have uncovered any problems at that point.

Paediatric registrar Dr Alison Bernard, who was on duty at the time, said in a statement that she tried to convince the family to stay in hospital, adding: “My primary concern was to keep him on the ward. If there had been any concern about his health I would have examined him.

“He should have been examined before 24 hours but no antenatal plan was made.”

When the family were discharged from the hospital at around 5.30pm on May 17 they were told by staff to return if there were any problems or changes in Tobias's condition, including vomiting.

“I do believe if she had come in at midnight when he clearly wasn't right then he could have been saved” - Dr Debbie Pullen

In Mrs Taylor's statement, read out at the inquest, she said Tobias would not feed, passed a white stool and was sick during the night so she took him to hospital the following morning. She said she was concerned staff had let her return home.

Giving evidence, Dr Debbie Pullen, the consultant paediatrician who saw Tobias when he returned to hospital on May 18, said: "I knew he had perforated his bowel and had septicaemia the minute I saw him.

“From speaking to his mum it was clear he hadn't been well from around midnight.

“I feel she was given very clear instructions on when to come back and I do believe if she had come in at midnight when he clearly wasn't right then he could have been saved.

“I think there was an opportunity to intervene."

Tobias was rushed to St George's where he was taken into theatre and put on a life support machine. But, suffering from multiple organ failure, his parents switched it off shortly after 6pm on May 19.

He died from septicaemia cause by meconium ileus, a condition where the contents of a baby's bowel are sticky, similar to cystic fibrosis, and causes a blockage which can lead to the bowel perforating.

Septic shock

Coroner Miss Hewitt recorded a verdict of death by natural causes and said careful monitoring of Tobias and an examination would have been "good practice" considering staff knew about the potential risks he faced.

She added: "Although it seems there wasn't a very good reason why that examination wasn't done at some point before 5.30pm, I'm very conscious of the evidence that up until that point Tobias was clinically well.

"There is no evidence before me to show examination before his discharge would have provided any further information on the risk of meconium ileus causing him problems, and it was still entirely possible that the situation would sort itself out naturally.

“Of course what happened at 5.30pm was that Tobias's mother discharged herself and him, and I have to find that was contrary to medical advice.

"A number of members of staff seeked to persuade her to stay and she agrees she signed the self-discharge form.

“It would seem that Tobias became unwell in the early hours of May 18 and that they brought him back to hospital at about 9am the following morning and by that time it's clear the chances of any intervention and helping him to survive were, I suspect, remote and, in any event, it would seem the transfer to St George's led to all steps that could be taken at that stage being taken, but to no avail given that he was at that time in septic shock.

“The result of all that is it did not seem to me I could point at any one or more interventions that might have taken place upon which I could say, probably, he would have survived.

“Certainly prior to his discharge, it's impossible to know from the evidence, whether examination, abdominal X-ray or other intervention would have made a difference to the outcome.”

She commended the team at East Surrey Hospital for addressing the problems highlighted in the case, including introducing a new self-discharge process and a new electronic system to flag up births which could have complications, and for improving communication between departments.

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She has been editorial director of the online and print titles in Surrey and north-east Hampshire since 2007. Marnie previously worked at the BBC as a producer for 5 Live, having moved to national radio from BBC Sussex and Surrey.